Cathy Brown

-Conduct initial in-home psychosocial assessments to identify needs of both the patient and family, providing on-going individualized case management and end of life education.

-Provide emotional support to patients and families navigating end-of-life decisions, assisting with referral to community resources, completion of Advanced Health Directives, funeral planning, financial planning while assuring end of life wishes are honored.

-Maintain accurate documentation of all social work interventions in accordance with regulatory requirements and organizational policies.

-Completion of comprehensive care plans tailored to individual patient and family needs.

-Weekly collaboration with the interdisciplinary team to discuss patient progress and adjustments in care.

-Facilitate grief counseling sessions for family members coping with loss, assessing for bereavement risk and potential experience of complicated grief.

-Maintain a strong network of community partnerships, enhancing resource availability for patients and families during their time of need.

-Completion of initial psychosocial interview and assessments, BIMS, PHQ-9 and Trauma Informed Care screening tools upon admission to Skilled Nursing Facility.

-Timely input of MDS admission, quarterly and annual assessments and interviews

-Scheduled and facilitated admission, quarterly and annual care plan meetings

-Developed and updated individualized psychosocial care plans

-Coordination of ancillary services for residents in both Skilled Nursing and Assisted Living

-Participated in daily Interdisciplinary Team meetings and monthly OAPI meetings

-Maintained social work documentation within regulatory guidelines

-Provided staff educational in-services including resident rights, policy and procedure, psychotropic medications and chronic health conditions

-Timely completion of admission, quarterly, annual and discharge Skilled Nursing Facility psychosocial assessments.

-Creation and quarterly update of residents individualized psychosocial care plans

-Coordination and facilitation of residents care plan meetings upon admission, quarterly and discharge.

-Organized and facilitated monthly Resident Council and Family Council meetings.

-Completion of required social work documentation per regulatory standards.

-Conducted community outreach to raise awareness of available rehabilitative programs offered

-Completion of initial in-home family caregiver psychosocial interview and assessments for San Bernardino and Riverside County funded supportive services and respite grants

-Coordination and management of caregiver respite grants and use of supportive services

-Screening and creation of individualized care plans for family caregivers, identifying caregiver depression, experience of anxiety and caregiver burnout

-Organization and facilitation of family caregiver outreach, education and support groups throughout Riverside and San Bernardino Counties